'When you hear hoofbeats, think of horses not zebras' - the old adage is well-known to GPs but what should you do when faced with a zebra, not a horse? Consultant cardiologist Professor Robert Tulloh and GP Dr Louise Tulloh kick off our new series with their advice on how to catch Kawasaki disease in general practice.

Taking back control

As an FY2, I remember the walk of shame through the A&E waiting room to use our staff toilet. I could feel eyes boring into my back as I was about to cash in my one 30-second sit down of the shift. Sometimes I’d look at the hordes of people in that room, and a feeling of helplessness would flood my caffeine-soaked brain and sink right down into my aching feet.

I’d go home and wonder: how can we ever really improve things? Laying out the equation in my simple brain didn’t give me much hope. Demand will only increase. And much as we might think it’s the answer, I don’t think we’ll ever have enough money. Or staff. Or time.

I remember coming across this animation by Dan Pink on the way home after a long A&E shift. He lists three elements that motivate people, and produce a happy and productive workforce: autonomy, mastery, and purpose. More than money, he suggests that this trio drives, engages, and stimulates us to do our best work.

Medicine inherently has that trio at its core. But that day I remember wondering - will they always be drowned out by the pressures of the system I work in? (And would we ever be able to change that route to the toilet?)

It’s easy to think general practice is no different. The busy-ness of our day feels like it’s everyone else’s fault but ours. Any patient can call up, and get themselves seen. And when we’ve filled all the slots, we simply magic new ones out of thin air and add them to the end. Until the cleaner needs to lock up and go home.

But if I pause a moment and take a step back, it’s not quite like working in A&E. Trying to think about really changing things in a money-hungry, labyrinthine beast like a hospital is overwhelming. But general practice is different.

It was a Friday morning, and the waiting room was half empty. Steve turned on the computer. I felt the familiar dread that I’ve been conditioned to feel on loading up the appointment screen. But it was virtually blank, other than just a few reviews which he’d booked in himself. I was tempted to suggest he restart it.

Steve explained that the morning is kept clear for telephone calls. All patients that call the practice have to speak to a doctor first. The GP might resolve their query on the phone, or decide when and who they should be seen by- and even the length of the appointment they’ll need. The calls are done in the same office, with GPs, nurses, and receptionists sitting side by side.

Something occurred to me then. Ask a senior manager in another industry to cede control of their diaries to their customers, and they’d laugh. But that’s how most GPs work. It’s unsurprising that each day can feel like warfare.

Just over a year ago the practice was struggling to recruit and drowning under insatiable demand. For Steve, changing how he works has started to bring the joy back into what he does. He sees patients that really need to be seen, and can give them the time and continuity that he knows makes all the difference.

Creating a bit of headspace also allowed him to make some other improvements. They’ve introduced a new role called ‘Health Coaches’, who each take on a list of complex patients and oversee their social work, care navigation and basic clinical needs. Steve steps in with his medical expertise when he’s needed. No more hours playing phone ping-pong trying to work out how to get a commode.

Three times a week the practice also comes together for a ‘team huddle’, where they discuss their most complex patients. Every person in the building joins in, including the receptionists and admin staff who often spot problems before anyone else.

But I was reminded how that locus of control is a bit closer in general practice. It takes time, and a willingness to consider working differently- both of which we’ll never feel we have enough of. But as GPs we’re one step closer to our patients, our staff, and the culture of our workplace to really shape the way we work.

It’s a unique strength of general practice. The difference to secondary care is stark, but something we can take for granted. Especially once you’ve been out of a monolithic hospital for a while - and forgotten what it’s like to walk through a waiting room to the toilet.

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Readers' comments (5)

'Ask a senior manager in another industry to cede control of their diaries to their customers, and they’d laugh.'Not quite the right analogy.

More appropriate would be the senior managers requesting pilots pile more people into the corridors of the planes and on each others laps if the plane is full and ensuring the plane is free for anyone who needs to use it, rather than increasing the price and/or using the increased income to schedule more planes and more pilots!

Yes these dr first type systems can be pleasing at first, but quickly the number of calls for stupid nonsense just grow out of all control and you end up worse than before, except now it's telephone so even more risky.

It amazes me that even though all the evidence points towards improving access just leads to more demand, people still think they can reinvent the wheel and that improving access will magically transform the demand.

The majority of consultations, in my experience, can be done over the phone. However, as has previously been said, the improved access eventually leads to ever increasing demand. The only answer will be some form of copayment. This acts as a partial brake on demand and perhaps, more importantly, also allows extra income to flow into the practice in proportion to workload.

Well done on the article, the content is excellent and ties in with work I've been doing re: 'What is it that differentiates a SUCCESSFUL GP from a good one'?Autonomy, mastery and purpose. To these I would add Ownership. It has been shown across many studies that people take far more pride in personal satisfaction in work where they were involved in the creation of the final product or service. Of course unless one is either regularly innovating, or has the opportunity to create bespoke services for the target population, it is difficult to take ownership in a practice where things can feel very much 'routine' day to day.I recognise the concerns of some of my fellow commentators. It doesn't take long for word to spread that it is easy to get a phone consultation, or that it requires only a few key 'trigger phrases', so to speak, to almost guarantee a same day appointment for a patient who wants to game the system.The other issue is that there are many GPs who really don't like phone triage and/or have had a bad experience of it. I have worked in Out-of-hours for several years and am quite comfortable in the triage settings but some GPs won't even consider it. I entirely agree though that ceding control of our workday entirely to the whim of the general public is quite ridiculous and unsustainable, and my view is simply to refuse the endless 'See your GP for...' requests that land on our doorstep daily. Taking control back certainly involves re-establishing boundaries so that being able to see a doctor regains its status as a privilege, rather than a God-given right at any time on any whim.I'm all for further discussion on 'taking back control' - it's about time!